jksr Journal of the Korean Society of Radiology J Korean Soc Radiol 1738-2637 2288-2928 The Korean Society of Radiology 10.3348/jksr.2020.81.1.21 jksr-81-21 Review Article Optimization of MRI Protocol for the Musculoskeletal System 0000-0003-2427-2783 LeeHong SeonMD 1 2 0000-0002-5602-391X LeeYoung HanMD 1 2 ∗ 0000-0001-5999-1281 JungInhaMD 1 2 0000-0002-3914-9203 SongOk KyuMD 1 2 0000-0002-7876-7901 KimSungjunMD 2 3 0000-0002-6655-2575 SongHo-TaekMD 1 2 0000-0001-9455-9240 SuhJin-SuckMD 1 2 Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science (CCIDS), Yonsei University College of Medicine, Seoul, Korea Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Corresponding author Young Han Lee, MD Department of Radiology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. Tel 82-2-2228-7400 Fax 82-2-2227-8337 E-mail radiologie@gmail.com 12020 712020 811 2140 30102019 08012020 21012020 Copyright © 2020 The Korean Society of Radiology 2020 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract

Magnetic resonance imaging (MRI) is an essential modality for the diagnosis of musculoskeletal system defects because of its higher soft-tissue contrast and spatial resolution. With the recent development of MRI-related technology, faster imaging and various image plane reconstructions are possible, enabling better assessment of three-dimensional musculoskeletal anatomy and lesions. Furthermore, the image quality, diagnostic accuracy, and acquisition time depend on the MRI protocol used. Moreover, the protocol affects the efficiency of the MRI scanner. Therefore, it is important for a radiologist to optimize the MRI protocol. In this review, we will provide guidance on patient positioning; selection of the radiofrequency coil, pulse sequences, and imaging planes; and control of MRI parameters to help optimize the MRI protocol for the six major joints of the musculoskeletal system.

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Dedicated shoulder RF coil. The shoulder is slightly externally rotated, and the shoulder cup of the RF coil is attached to the shoulder using the height adjustment bar. Since the shoulder joint is an off-center joint, it should be positioned at the center of the bore and the RF coil should be closely attached to the shoulder joint. RF = radiofrequency

Imaging plane of shoulder MRI. A-D. In shoulder MRI, based on axial images (A and C), the oblique coronal images (B) are obtained at right angles to the glenoid fossa (A), and the oblique sagittal images (D) are obtained perpendicular to the oblique coronal plane or parallel to the glenoid fossa (C). On the oblique coronal image (B), the glenoid labrum (asterisks) and the long course of the supraspinatus tendon and its attachment (arrow) to the greater tuberosity are well visualized. On the oblique sagittal image (D), the muscles forming the rotator cuff (asterisks) are visible. Clockwise from the 12 o’ clock position, the supraspinatus muscle, infraspinatus muscle, teres minor muscle, and subscapularis muscle are depicted.

Elbow flexible RF coil. The coil is a flexible RF coil that can be used for small joints. The patient is in close contact with the elbow joint. Depending on the physique of the patient, small and medium sizes are available. RF = radiofrequency

Dedicated wrist RF coil. By using the RF coil dedicated to the wrist joint, the patient can main-tain the joint in a neutral position while laying supine, thereby enabling stable image acquisition. The superman position may be considered to place the wrist joint at the center of the magnetic field. However, if the acquisition time is long, the patient may feel uncomfortable. RF = radiofrequency

Torso RF coil for hip joint imaging. The coil is a multi-channel torso RF coil that can cover a wide field of view required for hip joint MRI, enabling imaging of both the hips and pelvic bones. RF = radiofrequency

Dedicated knee RF coil. A type of dedicated RF coil for the knee joint, which can be separated up and down. When the knee joint is placed inside the coil, it is slightly flexed. Recently, radiologists have begun using the transmit-receiver coil, in which case the connectors are located on both sides. RF = radiofrequency

Dedicated ankle RF coil. The ankle joint RF coil is designed so that the lower leg and the foot are al-most at right angles to each other, enabling correct posture for imaging. If a flexible coil is used, a positioner may be used to enhance patient comfort. RF = radiofrequency

Musculoskeletal MRI Scan Parameters

  Shoulder Elbow Wrist Hip (screening) Hip (focused) Knee Ankle
Field of view (cm) Shoulder 16↓ Elbow 10–16 Wrist 6–12 Hip (screening 35–45 ) Hip (focused) 16–20 Knee 16↓ Ankle 14↓
Slice thickness (mm) 3↓ 3–4 3↓ 6–8 3–4 3↓ 3↓
Interslice gap (%) 10↓ 33↓ 33↓ 33↓ 33↓ 10↓ 10↓
Matrix size 256 × 192↑ 256 × 256↑ 256 × 192↑ ↑ 512 × 384↑ 256 × 192↑ 256 × 192↑

↓ = less than or equal to, ↑ = greater than or equal to

Shoulder: Scan Coverage and Anatomical Structures Involved

  Scanning Axis and Coverage Anatomic Structures
Oblique coronal Anteriorly, coracoid process Posteriorly, scapular spine Rotator cuff, acromioclavicular joint, biceps long head tendon, glenoid labrum, glenohumeral ligament, axillary recess, deltoid muscle
Oblique sagittal Medially, spinoglenoid notch Laterally, greater tuberosity of humerus Rotator cuff, acromioclavicular joint, rotator interval, biceps long head tendon, coracohumeral ligament, glenohumeral ligament
Axial Superiorly, acromioclavicular joint Infeiorly, axillary recess Acromioclavicular joint, subscapularis tendon, biceps long head tendon, labrum, coracohumeral ligament

Elbow: Scan Coverage and Anatomical Structures Involved

  Scanning Axis and Coverage Anatomic Structures
Axial Perpendicular to humerus and proximal radius and ulna Humerus epicondyle and radial tuberosity should be included Distal biceps and brachialis, common flexor tendon and common extensor tendons, ulnar nerve and adjacent structures
Coronal Parallel to epicondylar axis Must include soft tissue in the anterior and posterior aspect Collateral ligament complex, common flexor tendon, common extensor tendon
Sagittal Perpendicular to the epicondylar axis Radiocapitellar and ulnotrochlear joint, triceps brachii tendon

Wrist: Scan Coverage and Anatomical Structures Involved

  Scanning Axis and Coverage Anatomic Structures
Coronal Parallel to the line ulnar styloid process and radial styloid process From Lister's tubercle to proximal metacarpal bones Triangular fibrocartilage complex, wrist ligaments, carpal bone, radiocarpal joint, radiocarpal, intercarpal, and carpometacarpal joints
Axial Parallel to distal radius From proximal metacarpal bones to metaphysis of distal radioulna Carpal tunnel, Guyon's canal, flexor tendons, extensor tendons, intrinsic ligaments, neurovascular bundle, distal radioulnar joint
Sagittal Perpendicular to coronal plane From distal radioulnar joint to proximal metacarpal bones Flexor tendons, extensor tendons, bone alignment

Hip: Scan Coverage and Anatomical Structures Involved

  Scanning Axis and Coverage Anatomic Structures
Coronal Includes iliac bone, greater trochanter of femur, and proximal femur Pelvic bones (ilium, pubis, ischium, sacrum), labrum, cartilage, femur and acetabulum, greater trochanter, trochanteric bursa
Axial Bilateral: iliac wing to both greater trochanter/ proximal femur Ipsilateral: anterior superior iliac spine to both greater trochanter/proximal femur Anterior and posterior labrum, cartilage, femur and acetabulum, sciatic nerve, greater trochanter, trochanteric bursa, joint capsule
Sagittal Perpendicular to axial and coronal plane Labrum, cartilage, femur and acetabulum, bursa

Knee: Scan Coverage and Anatomical Structures Involved

  Scanning Axis and Coverage Anatomic Structures
Axial Parallel to the medial femoral condyle and lateral femoral condyle Superiorly, distal quadriceps muscle and suprapatella bursa Inferiorly, patella tendon, tibial attachment of pes anserinus tendon, tibial tuberosity Articular cartilage of patella, trochlear cartilage, patellofemoral joint, meniscus, collateral ligament, cruciate ligament, posterolateral corner, posteromedial corner
Coronal Parallel to midline of femur and tibia. Parallel to medial femoral condyle and lateral femoral condyle Includes medial collateral ligament and lateral collateral ligament, fibular head, meniscus Meniscus, collateral ligament, cruciate ligament, posterolateral corner, posteromedial corner, articular cartilage of tibiofemoral joint
Sagittal Parallel to lateral femoral condyle Includes distal quadriceps muscle and tendon and tibial tubercle and meniscus Articular cartilage of tibiofemoral joint, trochlear cartilage, meniscus, cruciate ligament

Ankle: Scan Coverage and Anatomical Structures Involved

  Scanning Axis and Coverage Anatomic Structures
Coronal Perpendicular to axial scans Include calcaneus and metatarsal base Deltoid ligaments, calcaneofibular ligament, tarsal tunnel, plantar fascia
Axial Parallel to the longitudinal axis of calcaneus including distal tibia and inferior margin of calcaneus Posterior tibial tendon, peroneus longus/ brevis tendon, sinus tarsi, tibiofibular ligament, anterior talofibular ligaments, posterior talofibular ligament, spring ligament
Sagittal Parallel to the longitudinal axis of talus including both medial and lateral margin Achilles tendon, sinus tarsi, plantar fascia